Fmc - Columbus Bartholomew

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 48658 Based on observation, record review, and interview, the facility failed to follow applicable infection control procedures when disposing of used sharps for 1 of 2 observations for initiation of dialysis with central venous catheter (Patient #2). Findings include: 1. Review of a policy titled “Drawing Labs Pre and Post Treatment Procedure” (Version 4; 09/05/2023) indicated: “After all blood tubes are filled and removed from vacutainer, clamp catheter and remove adapter and needle holder. Discard vacutainer needle holder with the needle intact in a sharp container.” 2. During an observation on 05/14/2025 at 10:47 AM, LPN 1 disposed of a used vacutainer needle holder with the needle (a blood transfer device) into the regular waste bin. LPN 1 failed to dispose of blood transfer device into sharps container. 3. During an interview on 05/14/2025 at 11:25 AM, LPN 1 stated blood transfer devices are to be disposed of in sharps container, not regular waste. 4. During an interview on 05/16/2025 at 12:38 PM, RN 2 indicated that all sharps are to be disposed of in the sharps container, not regular waste. 5. During an interview on 05/16/2025 at 1:05 PM, PCT 1 indicated that all needles, syringes and lab tubes are to be disposed of in the sharps container, not regular waste.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 48658 Based on observation, record review, and interview, the facility failed to ensure staff followed standard infection control practices when wearing personal protective equipment (PPE) to include gloves and fluid resistant gowns, and station disinfection for 1 of 1 isolation room observations. ( Findings Include: Review of a policy titled “Cleaning and Disinfecting the Dialysis Station” (Version 14; 09/05/2023) indicated staff should: “Follow the steps below to disinfect the dialysis station after each dialysis treatment: 1. Don the appropriate PPE... Place the chair in Trendelenburg position and open side panels if chair has swing open sides so all surfaces of the chair are accessible...” Review of a policy titled “Personal Protective Equipment” (Version 6; 11/06/2023) indicated: “Employees shall use personal protective equipment in accordance with the type of patient contact expected and anticipated exposure.” During an observation on 05/14/2025 at 11:20 AM, RN 1 disinfected the isolation room chair using a bleach solution. RN 1 failed to open the left side of the arm rest to adequately disinfect. Her fluid resistant gown continuously slipped down and had to be readjusted throughout the entire disinfection process due to improperly wearing/securing the gown. She failed to secure the gown around her neck and waist as intended for use. RN 1 then removed her gloves and proceeded to gather the regular waste bag from the waste can, tied it in a knot to secure, and disposed of the waste in the biohazard bin with her bare hands. During an interview on 05/14/2025 at 11:25 AM, RN 1 indicated she forgot to open and disinfect the inside of the chair but would go back to disinfect before the next patient arrives. She noticed her fluid resistant gown kept falling off but thought if she stopped to secure it properly, she would contaminate what she had already disinfected. She stated that gloves are to be worn when emptying trash into the biohazard bin. During an interview on 05/16/2025 at 12:38 PM, RN 2 indicated that station disinfection is to include opening the arms of the chair and disinfecting with bleach and that PPE, gloves & gowns, are required to be worn properly and not altered in any way when disinfecting stations and gathering waste. During an interview on 05/16/2025 at 1:05 PM, PCT 1 indicated PPE to include gloves and gowns are to be worn when disposing of waste and station disinfection. PPE is not to be altered or improperly worn.”